Updated Acute Otitis Externa Guideline Garners AAFP Endorsement

FP Expert Reviews Key Points

Acute otitis externa (AOE), also known as "swimmer's ear," accounted for 2.4 million U.S. health care visits in 2007 -- that's 8.1 visits per 1,000 population -- according to an article in the May 2011 Morbidity and Mortality Weekly Report (MMWR).(www.cdc.gov) From 2003-2007, children ages 5-14 represented more than 34 percent of these cases, which peaked during the summer months.

The MMWR report also estimated that direct health care costs for nonhospitalized AOE visits during this period totaled as much as $500 million annually, and ambulatory care clinicians spent nearly 600,000 hours each year treating the condition.

Now, an updated guideline(oto.sagepub.com) from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) provides evidence-based recommendations for managing AOE. After carefully evaluating the guideline, which was published in February as a supplement to the journal Otolaryngology-Head and Neck Surgery, the AAFP endorsed it in September.

AAFP member Kaparaboyna Kumar, M.D., of San Antonio, served on the AAO-HNSF guideline panel. Kumar is a distinguished teaching professor and director of the family medicine clerkship in the Department of Family and Community Medicine at the University of Texas Health Science Center at San Antonio.

Guideline Overview

Kumar told AAFP News that the guideline panel placed particular emphasis on patient education and counseling with the addition of new tables that list common questions with clear and simple answers.

Story highlights

The Academy has endorsed an acute otitis externa (AOE) guideline that places extra emphasis on patient education and counseling.

It is important for clinicians to differentiate diffuse AOE from other causes of ear pain, such as furunculosis and dermatitis of the external ear canal, because the treatments for these conditions are completely different.

According to the panel that developed the guideline, it's worth noting that the pain related to AOE can be disproportionately severe to what might be expected based on visual examination.

"We also provided instructions to clinicians about proper administration of ear drops," he said, "and we expanded the action statements to explicitly state confidence in the evidence and difference of opinion amongst the guideline development committee members."

Kumar added that the guideline panel -- which included not only members of the otolaryngology-head and neck surgery community, but also pediatrics, infectious disease, family medicine, dermatology and consumer representatives -- enhanced the external review process to include public comment and journal peer review, updating all supporting text.

Key Takeaways

Kumar highlighted four key points from the guideline for AAFP News.

First, it is important for clinicians to differentiate diffuse AOE from other causes of ear pain, such as furunculosis and dermatitis of the external ear canal, because the treatments for these conditions are completely different. Physicians should follow up and reassess any patient diagnosed with AOE within 48 to 72 hours if he/she fails to respond to initial treatment to confirm the diagnosis of diffuse AOE and exclude other causes of illness.

Second, most cases of AOE are caused by bacterial infection and respond well to topical antibiotic drops, which can be 100 to 1,000 times more concentrated than systemic agents when administered correctly, said Kumar. "Cleaning of the ear and applying a wick facilitates the drops to reach inside the ear canal where the topical antibiotics will be most effective," he noted.

Third, physicians should not prescribe systemic antibiotics as initial therapy unless there is extension of inflammation outside the ear or the patient has complicating health conditions such as diabetes or immunodeficiency. "Systemic antibiotics are unnecessary to treat diffuse AOE in most patients," Kumar said. "(These drugs) have side effects and also can be expensive."

And finally, it's worth noting that the pain related to AOE can be disproportionately severe to what might be expected based on visual examination, said Kumar. "Therefore, assessment of pain and appropriate measures to relieve pain are important, including prescription of opiates," he said.

In addition, clinicians need to take special precautions when treating a patient who has a perforated eardrum or tympanostomy tubes, including prescribing safer antibiotic ear drops to avoid ototoxicity.

Physicians may wish to consult the full recommendation for further details, including educational information for patients and a treatment algorithm.